Margaret Gleason, RN,
Deidra Gradishar, RNC, BS
NANDA: State in which a person experiences difficulty in
performing tasks of daily living, such as feeding self, dressing, bathing,
toileting, transferring from bed, and walking
The nurse may encounter the patient with a self-care deficit in
the hospital or in the community. The deficit may be the result of transient
limitations such as those one might experience while recuperating from surgery
or the result of progressive deterioration that erodes the individual's ability
or willingness to perform the activities required to care for themselves.
Careful examination of the patient's deficit is required to be certain that the
patient is not failing at self-care because of a lack in material resources or
a problem with arranging the environment to suit their physical limitations.
The nurse coordinates services to maximize the independence of the patient and
to ensure that the environment that the patient lives in is safe and supportive
to their special needs.
- Neuromuscular impairment, secondary to cerebrovascular
- Musculoskeletal disorder such as rheumatoid arthritis
- Cognitive impairment
- Energy deficit
- Inability to feed self independently
- Inability to dress self independently
- Inability to bathe and groom self independently
- Inability to perform toileting tasks independently
- Inability to transfer from bed to wheelchair
- Inability to ambulate independently
- Inability to perform miscellaneous common tasks:
- Patient safely performs (to maximum ability) self-care
- Resources are identified which are useful in optimizing the
autonomy and independence of the patient.
- (i) independent
- (i) Assess ability to carry out ADLs (feed,
dress, groom, bathe, toilet, transfer, and ambulate) on regular basis.
Determine the aspects of self-care that are problematic to the patient.
- The patient may only require assistance with some self-care
- (i) Assess specific cause of each deficit
(e.g., weakness, visual problems, cognitive impairment).
- Different etiologic factors may require more specific
interventions to enable self-care.
- (i) Assess patient's need for assistive
- To increase independence in ADLs performance.
- Assess for need of home health care after discharge.
- Shortened hospital stays mean that patients are more
debilitated on discharge from the hospital and that patients need more
assistance after discharge.
- (i) Identify preferences, food, personal care
items, and other things.
- To support patient's individual and personal
- (i) independent
- (i) Assist patient in accepting necessary
amount of dependence.
- If disease, injury, or illness resulting in self-care
deficit is recent, patient may need to grieve before accepting that dependence
- (i) Set short-range goals with patient.
- To facilitate learning and decrease frustration.
- (i) Encourage independence, but intervene when
patient cannot perform.
- To decrease frustration.
- (i) Use consistent routines and allow adequate
time for patient to complete tasks.
- This helps patient organize and carry out self-care
- (i) Provide positive reinforcement for all
activities attempted; note partial achievements.
- This provides the patient with an external source of
patient to feed self as soon as possible (using unaffected hand, if
appropriate). Assist with setup as needed.
- It is probable that the dominant hand will also be the
affected hand if there is upper extremity involvement.
- (i) Ensure that patient wears dentures and
eyeglasses if needed.
- Deficits may be exaggerated if other senses or strengths
are not functioning optimally.
- (c) Assure that consistency of diet is
appropriate for patient's ability to chew and swallow, as assessed by speech
- Mechanical problems may prohibit the patient from
- (i) Provide patient with appropriate utensils
(e.g., drinking straw, food guard, rocking knife, nonskid placemat) to aid in
- These items increase opportunities for success.
- (i) Place patient in optimal position for
feeding, preferably sitting up in a chair; support arms, elbows and wrists as
- (i) Consider appropriate setting for feeding
where patient has supportive assistance yet is not embarrassed.
- Embarrassment or fear of spilling food on self may hinder
patient's attempts to feed self.
- (i) If patient has visual problems, advise the
patient of the placement of food on the plate.
- Following CVA, patients may have unilateral neglect, and
may ignore half the plate.
Provide privacy during dressing.
- Patients may take longer to dress, and may be fearful of
breeches in privacy.
- (i) Provide frequent encouragement and
assistance as needed with dressing.
- To reduce energy expenditure and frustration.
- (i) Plan daily activities so patient is rested
- (c) Provide appropriate assistive devices for
dressing as assessed by nurse and occupational therapist.
- The use of a button hook or of loop and pile closures on
clothes may make it possible for a patient to continue independence in this
- (i) Place the patient in wheelchair or
- To assist with support when dressing. Dressing can be
- (i) Encourage use of clothing one size
- To ensure easier dressing and comfort.
- (i) Suggest brassiere that opens in front and
- Which may be easier to manage.
- (i) Suggest elastic shoelaces or loop and pile
closures on shoes.
- To eliminate tying.
- (i) Provide make-up and mirror; assist as
- Fine motor activities may take more coordinated actions and
may be beyond the abilities of the patient.
Maintain privacy during bathing as appropriate.
- The need for privacy is fundamental for most
- (i) Ensure that needed utensils are close
- To conserve energy and optimize safety.
- (i) Instruct patient to select bath time when
they are rested and unhurried.
- Hurrying may result in accidents and the energy required
for these activities may be substantial.
- (i) Provide patient with appropriate assistive
devices (long-handled bath sponge; shower chair; safety mats for floor; grab
bars for bath or shower).
- To aid in bed bathing.
- (i) Encourage patient to comb own hair (a
one-handed task). Suggest hairstyles that are low-maintenance.
- To enable the patient to maintain autonomy for as long as
- (i) Encourage patient to perform minimal
oral-facial hygiene as soon after rising as possible. Assist with brushing
teeth and shaving, as needed.
- (i) Assist patient with care of fingernails
and toenails as required.
- Patients may require podiatric care to prevent injury to
feet during nail trimming or because special implements are required to cut
- (i) Offer frequent encouragement.
- Patients often have difficulty seeing progress.
(i) Evaluate or
document previous and current patterns for toileting; institute a toileting
schedule that factors these habits into the program.
- The effectiveness of the bowel or bladder program will be
enhanced if the natural and personal patterns of the patient are
- (i) Provide privacy while patient is
- Lack of privacy may inhibit the patient's ability to
evacuate their bowel and bladder.
- (i) Keep call light within reach and instruct
patient to call as early as possible.
- So staff members have time to assist with transfer to
commode or toilet.
- (i) Assist patient in removing or replacing
- Clothing that is difficult to get in and out of may
compromise a patient's ability to be continent.
- (i) Encourage use of commode or toilet as soon
- Patients are more effective in evacuating bowel and bladder
when sitting on a commode. Some patients find it impossible to toilet on a
- (i) Offer bedpan or place patient on toilet
every 1 to 1.5 hours during day and three times during night.
- To eliminate incontinence. Time intervals can be lengthened
as the patient begins to express the need to toilet on demand.
- (i) Closely monitor patient for loss of
balance or fall.
Keep commode and toilet tissue near the bedside for
- Patients may rush readiness to ambulate to the toilet or
commode during the night because of fear of soiling themselves and may fall in
(i) Plan teaching session for transferring/walking when
patient is rested.
- Tasks require energy. Fatigued patients may have more
difficulty and may become unnecessarily frustrated.
- (i) Assist with bed mobility.
- To prevent disabling contractures, pressure sores, and
muscle weakness from disuse by doing the following:
- Encourage to use the stronger side (if appropriate) as best as
- Stroke patients experience weakness in their dominant
side; therefore it will be necessary for them to develop muscle strength and
coordination on the stronger side.
- Allow patient to work at own rate of speed.
- Many factors may influence a patient's ability to move
freely and each of these factors must be considered when developing/teaching a
patient a new system for self-care. It will take time for the patient to learn
and then gain confidence in his or her ability to perform these new self-care
- When patient is sitting up at side of bed, instruct him or her
not to pull on caregiver.
- This may cause caregiver to lose balance and
- (i) When transferring to wheelchair, always
place chair on patient's stronger side at slight angle to bed and lock brakes.
- Patient will weight-bear on the strong side.
- (i) When minimal assistance is needed, stand
on patient's weak side, place nurse's hand under patient's weak arm.
- (CAREGIVER: Keep your
feet well apart; lift with legs, not back, to prevent back strain).
- (i) For moderate assistance, place caregiver's
arms under both armpits with caregiver's hands on patient's back.
- This forces patient to keep his or her weight
- (i) For maximum assistance, place right knee
against patient's strong knee, grasp patient around waist with both arms, and
pull him or her forward; encourage patient to put weight on strong side.
- This stance maximizes patient support while protecting the
care provider from back injury.
- (i) Assist with ambulation; teach the use of
ambulation devices such as canes, walkers and crutches.
- Stand on patient's weak side.
- To enhance patient safety.
- If using cane, place cane in patient's strong hand and ensure
proper foot-cane sequence.
- To assist with balance and support.
- Miscellaneous Skills
Telephone: Evaluate need for adaptive equipment through therapy department
(pushbutton phone, larger numbers, increased volume).
- Patients will require an effective tool for communicating
needs from home.
- (i) Writing: Supply patient with felt-tip
- These mark with little pressure and are easier to
- Evaluate need for splint on writing hand.
- To assist with holding the writing device.
- (i) Provide supervision for each activity
until patient performs skill competently and is safe in independent care;
reevaluate regularly to be certain that the patient is maintaining skill level
and remains safe in environment.
- The patient's ability to perform self-care measures may
change often over time and will need to be assessed regularly.
- (i) Encourage maximum independence.
Education/Continuity of Care
- (i) independent
- (i) Plan teaching sessions so patient has time
to practice tasks.
- (i) Instruct patient in use of assistive
devices as appropriate.
- (i) Teach family and caregivers to foster
independence and to intervene if the patient becomes fatigued, is unable to
perform task, or becomes excessively frustrated.
- This demonstrates caring and concern, but does not
interfere with patient's efforts to achieve independence.
Self-Care Assistance: Bathing/Hygiene; Self-Care Assistance:
Dressing/Grooming; Self-Care Assistance: Feeding; Self-Care Assistance:
Toileting; Environment Management
- See also:
Physical Mobility, Impaired, Chapter 3, p. 154
Self-Esteem Disturbance, Chapter 3, p. 166
Activity Intolerance, Chapter 3, p. 20
~ Care Plan Index ~
Outcomes Index ~
~ Care Plan Constructor Home ~